Managing depression – Lucas

Managing depression – analytic, antidepressants or both?

Richard Lucas*

INTRODUCTION severe of psychopathology, Freud and Abraham’s seminal papers remain as clinically In this paper, the analytic contribution to relevant, today, as when they were first the understanding and management of written.1,2 depression will be considered, together with Clinical material, taken from a patient who clinical illustrations, within the context of every had been in analysis, will be used to illustrate day general psychiatric practice. how informs on the Patients with major depression cover the psychopathology of depression. Material will spectrum, in terms of severity of the then be presented from patients not amenable psychopathology, between those who receive a to analysis, but showing how analytic insights purely analytic approach, those who may take help both to understand the process through medication while having analytic which the patient is undergoing and in providing psychotherapy, and those seemingly not a supportive framework to the professional amenable to other than a physical approach. carers and relatives, while they are having to The latter group features largely in endure very difficult periods, where the everyday psychiatry, where general depression appears to be unremitting in psychiatrists have to run large supportive character. Appreciating the dynamic of a outpatient clinics, where many patients are pathological superego in depression, taking prescribed antidepressant medication. over the driving seat, and the need to unseat it However, even in these cases, it does not and foster a more benign superego that exclude one from thinking analytically. When strengthens ego development, is a key issue trying to understand and relate to the most when relating to patients with depression, whether treating with antidepressant medication, psychotherapy or both3. In order to understand depressive illness, we also need to * Psiquiatra e Psicanalista, St Ann's Hospital, London. distinguish it from other causes of low mood and recognise its special psychopathology. Freud’s seminal paper, Mourning and 274 Melancholia, helps us to go beyond ordinary

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empathy, through recognising the underlying friend. An initial supportive response from the narcissistic structure1. However, his insights are carers’ deals with the immediate crisis and usually not incorporated within general medication is not indicated. In contrast, patients psychiatric training and practice, nor in contrast with features of psychotic depression are do psychoanalytic therapists think enough about typically older, there was a real intention to kill depression in terms of a psychotic disorder and themselves, and the treatment typically would how medication might be thought about, when involve medication and admission to a needed, in this context. psychiatric hospital.6, 7

DIFFERENT MEANINGS TO DEPRESSION GRIEF REACTIONS The first thing we need to do is to be clear In Mourning and Melancholia, Freud about four quite different ways that we may talk movingly described the process of mourning. about depression. Edith Jacobson, in her How, we try to turn away from reality and cling studies on depression, referred to them as onto the lost object through a hallucinatory normal, neurotic, psychotic and grief reactions4. wishful psychosis e.g. hearing the voice of our lost loved one. However reality gains the day NORMAL DEPRESSION and we have to relinquish the external object and reinstate its memory inside us and to do What Jacobson referred to, as normal this we have to go through the work of depression, is akin to what mourning.1 referred to as the depressive position. It is Freud interestingly contrasted mourning essentially a state of health, a capacity to bear with melancholia; the latter would now be guilt, stay in touch with mental pain and referred to as a severe depressive episode8. In emotional problems and bring thinking to bear melancholia, Freud surmised that there must on situations. In Kleinian terms, we oscillate have also been a loss for the patient; however between our ability to stay with painful situations one could not see the loss. He concluded that it or seek temporary relief through splitting and therefore must have been an internal projection, returning to the paranoid-schizoid narcissistic loss, occurring at an unconscious position, or flight into manic idealisations5. level, and requiring a separately considered understanding in its own right.1 NEUROTIC DEPRESSION PSYCHOTIC DEPRESSION Neurotic depression or reactive depression can be understood, simplistically speaking, as In modern day terminology, Jacobson’s an exaggerated response to stress due to a psychotic depression would be termed a severe weak state of ego strength combined with a depressive episode with psychotic symptoms8. failure of the external support system and Depression is, in fact, a very common condition. basically is a cry for help. Some 3% of the population are seeking help at any one time, while another 3% remain For example, an asylum seeker was undetected struggling on their own in the admitted to hospital after running in front of community. 10% also undergo manic episodes. cars. A flat mate reported how he had tried to In manic depression, there is a 15% risk of jump out of a window until restrained and then suicide, and up to 50% of patients may have took a few paracetamol tablets. He clinically visited their General Practitioners in the few presented in a withdrawn and retarded state, as weeks preceding suicide (Gelder et al., 2001). if undergoing a severe depressive episode, but Clearly, it helps to be familiar with the was fine the next day after we indicated that, if clinical presentation, as the patient may not contacted by his solicitors, we would write a complain of depression but only emphasise one supportive asylum appeal letter. of many commonly experienced symptoms and Two conditions, where the differentiation one may miss realising that the symptom is part of the underlying nature of the depression is of an underlying syndrome. The following are important is in the assessment of suicide and well known typical symptoms familiar to all with puerperal depression.. the young and is practicing psychiatrists: seen as a wish for temporary oblivion and a cry Diurnal mood variation, early morning for help in relation to clear external precipitants, wakening, and psychomotor retardation – a such as a family row or break up with a boy slowing up of all physical and mental processes 275

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– with resulting loss of appetite and weight, As Freud put it “an object loss was transformed decreased , amenorrhoea, constipation into an ego loss”1. So, when the patient and retardation (stupor). announces to the world that they are useless, Other features include agitation (a they are not really criticising themselves, but a ceaseless roundabout of painful thoughts), poor purported ideal that has temporarily let them concentration (depressive pseudo-dementia), down. The self-tormenting is then a tormenting agoraphobia, depersonalisation and of the ideal object that had abandoned them at a derealisation, a loss of energy (mimicking time of need. The sadomasochistic process of anaemia) and hypochondriacal features self- criticism, that so dominates depressive including headaches, chest pain, stomach pains episodes, goes on in a relentless fashion until it with associated cancer phobia, and atypical has run its course. facial pain (depressive equivalents) and suicidal Some experienced nursing staff will have thoughts.9 no difficulty in intuitively understanding the need There are compelling reasons why general to let this process run its course in hospital, psychiatrists regard depressive illness as a without demanding excessive physical biological disorder. They see the symptoms of a interventions. slowing up of psychological and bodily No true mourning, with relinquishment of processes as indicative of a medical disorder the object, can occur because of the unresolved requiring physical treatment. Also in depression, ambivalent dependence on an ideal object. One common neurotransmitters in the brain are is left struck how, after months of self-berating, depleted, and anti-depressants work by raising the patient then recovers their former their levels, supporting the view of a biochemical composure without showing the slightest disorder. According to traditional psychiatric curiosity about their whole recent experience in teaching there is no place for psychotherapy, hospital. other than of a supportive kind, while the patient The following serves as an amusing takes his medication and recovers from the example of recovery from a major depressive episode. episode and how we can be fooled into thinking However, the author’s perspective, in that we have been dealing with a neurotic writing this paper, is from the position of a disorder. After months in hospital in a withdrawn practising psychoanalyst, seeing some patients depressed state, a woman started to recover. with depression for individual analytic therapy, She then complained that her husband worked whilst also working in general psychiatry, which all day and then went to the pub in the evening includes prescribing medication. In such a leaving her on her own. We felt incensed on her position, one is forced to give further behalf that his non-supportive behaviour was a consideration as to why the need for differing significant contributory factor to the length of approaches, depending on the severity of the her depression and invited the husband up next depression. One finds that analytic thinking week for enlightenment to his wife’s needs. does not stop with the more When he arrived her attitude had completely psychotherapeutically inaccessible cases, on changed. She said that he worked very hard the contrary the curiosity increases as the during the day and was entitled to have a drink psychopathology become more extreme. in the evening before coming home! She had shifted her criticism, after many months in THE PSYCHOANALYTIC UNDERSTANDING hospital, from herself having failed to live up to OF DEPRESSION the ideal, onto her husband, and then quickly restored him to be the all- providing object. She It is impossible, by précis, to do justice to was then in a mental state ready to leave what one can draw from the richness and hospital but not in the least bit interested in why liveliness of Freud’s paper, “Mourning and she had been so long in hospital. Melancholia”1. Freud emphasised the oral roots to the Freud points out that, in depression, the psychopathology of depression, with regression dominating internal relationship is with an object to oral narcissism, as evidenced by a patient’s demanding total obedience, with the associated refusal to eat, when in a severely depressed illusion of being totally looked after by the object. state1. Expanding on this theme, Abraham2 The absolute identification breaks down when brilliantly and succinctly summarised the needs arise, but the identification with the dynamic factors underlying depression, as idealised object still remains, while the ideal follows: 276 object is being criticised for having let one down.

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A constitutional factor of an over home on her own. She described being in a accentuation of oral eroticism. depressed state for two years, but receiving no treatment. It took two years before she was able 1. A special fixation of the libido at the oral to get the first specialist assessment of her son. stage. It was several years later before she had her 2. A severe injury to infantile narcissism. second child, a healthy daughter. 3. Occurrence of the primary Mrs A’s opening remark to the analysis was disappointment pre-oedipally. striking, “I want to be a calm sensible person 4. Repetition of the primary disappointment with no feelings.” Since her mother spent her in later life. time in a manic omnipotent state ridiculing separate thinking this comment represents Mrs The following clinical material, taken from a A’s wish to conform to her mother’s patient who was in analysis, confirms Abraham’s requirements. However this statement points. underlines the central dynamic to understanding Mrs A was a woman in her fifties, who came depression, for with the desire for identification to analysis because of troublesome feelings of with an ideal object, there is no room for depression, isolation and lack of identity. She separate thinking or expression of needy had an autistic son with whom she struggled for feelings. All tensions related to ones own needs years to get specialist help for him. When he and how the idealised object is ignoring them stated to improve she turned to her own needs. gets projected and then experienced Psychiatrically speaking, she exhibited somatically. I will return further to this point in typical features of depression, with early relation to the use of medication. morning wakening, diurnal mood variation, lack The lack of availability of a containing of energy and hypochondriasis, experiencing mother was graphically illustrated in a dream, headaches, which she felt might have been where she went to get food from a supermarket. indicative of a brain tumour. She felt her life was There was no basket and she came out, arms not her own, especially feeling demands from full of tin cans. Suddenly, an aunt (mother’s her elderly mother and her autistic son. sister) shouted from a house window: “Where is For both parents it was their second your mother?” She dropped the cans and marriage. Her father was elderly, eccentric but opened her mouth to speak. It was full of blood warm hearted. Her mother was quite dismissive and bits of glass. towards him. The oral origins of the psychopathology are When Mrs A was born, her mother had a very apparent, with the brittleness of the breast depressive breakdown. For three months, Mrs and the aggressiveness to it. When badly A was sent away to a nanny. The nanny was depressed, Mrs A would also report a sensation reported to have neglected her and she was ill of having swallowed two tablets of stones that with jaundice and gastro-enteritis. It took three lay heavy on her stomach, i.e. the unresponsive months for the neglect to be discovered and for stone breasts of mother. Also it reminds one of her to be returned home. the Ten Commandments, two tablets of stone Throughout her childhood, her mother not to be disobeyed. remained predominantly in a withdrawn state in This history confirms all of Abraham’s bed. However, she remained very dominating points. The constitutionally inherited family and ridiculing in manner to her daughter. history of depression, her mother having a The grandmother would instruct Mrs A not breakdown when she was born; The fixation of to upset her mother. Mrs A had a very lonely the libido at the oral level, with the sensation of childhood, living in the countryside and would having swallowed the tablets of stone breasts befriend animals and plants. when depressed and also the oral Her one talent was painting. Her mother aggressiveness, with the cut glass in the mouth. was so envious of any challenge to her authority The severe injury to infantile narcissism that she put kitchen rubbish on a painting of Mrs was evidenced by her mother’s A that won a prize in her . unresponsiveness. The first disappointment Mrs A’s husband was supportive but often pre-oedipally, starting at birth with being left abroad on business. When her autistic son was with the neglectful nanny; with the repetition of born, it was a precipitate labour. He cried day the primary disappointment in later life, with her and night for months on end. She went to stay at mother’s lack of support at the time of the birth her mother’s but her mother couldn’t tolerate of the autistic child. her baby’s persistent crying, so she went back Over the years, I endeavoured to support 277

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the growth of a separate sensitive independent been unable in childhood to establish their good thinking self, but the pull to be the calm sensible objects and so feel secure in their inner world13. person with no feelings predominated. In the Bion’s insights on the container add further -counter-transference, this took the depth to our appreciation of the nature of the form of a superficial quality to her speech, in agitation. “Normal development follows if the which I was left feeling that I was an object that relationship between infant and breast permits never took anything in, but expect to be the infant to project a feeling, say, that it is dying regarded as the authority with nothing to learn. into the mother and to reintroject it after its This was the idealised object, with which she sojourn in the breast has made it tolerable to the wished to identify. infant . If the projection is not accepted In her paper on Manic Depressive States, by the mother, the infant feels that it is dying is Klein comments on this clinging to the stripped of such meaning that it has. It therefore pathological early severe superego as “the idea reintrojects, not a fear of dying made tolerable of perfection is so compelling as it disproves the but a nameless dread” (p.116)14. idea of disintegration” (p.270).10 In fact, each of the various symptoms of The experience with this patient helped me depression invites consideration from a dynamic in starting to arrive at an understanding of the perspective. The separation from the idealised role that medication played in treating other identification may link to developing a fear of patients. Freud initially referred to melancholia going out, as having any separate identity would as a narcissistic neurosis, later to be revised, bring down the wrath of a jealous god, resulting with his introduction of the structural model, as in agoraphobia. An analytic patient of mine a disease of the critical agency or superego1, 11. when depressed, would develop agoraphobia, In his paper “On Narcissism”, Freud linked to fears of having developed a shape to compared the healthy state of taking in mental her body, as if this represented individuality and food from parental figures, the anaclitic state, would draw hostile notice to her. with a self centred state in which no The loss of the ideal object, leads to development occurs, the narcissistic state12. In symptoms akin to mourning, with both the self depression, the narcissistic state predominates (depersonalisation) and the outer world and takes the form of a delusion of being at one (derealisation) feeling unreal. Patients with with an all providing primitive godlike superego, depression typically wake early and feel worse but also living in fear of being cast out, like from in the morning, feeling better as the day goes the Garden of Eden, if any questioning or on. Biological psychiatry has unsuccessfully curiosity develops. tried to explain these features in terms of diurnal If one develops any need emotional or variations in steroid levels, but the symptoms physical, such as a bout of flu, it is a criticism of can be also considered at an analytic level. the primitive god-like superego, who should A man with severe unrelenting depression, have prevented it happening, or oneself for not whom I saw supportively for a year, came following the correct path to prevent getting ill in weekly to out patients accompanied by his wife. the first place and this may trigger another After I had left, he was admitted and received depressive episode of self-berating. ECT, but sadly then took his own life. His The commonest symptom of depression is problem was that he could not come to terms one of extreme agitation, as at the moment of with, during the war, having killed in a fit of rage curiosity or questioning, one feels separated a Japanese soldier who was on the point of from being at one with the godlike superego. surrendering, because the Japanese had This results in a feeling of being completely recently killed his friend, whom he had found unheld, like a newly born baby left on a changing with his head smashed open. He would wake up mat shaking with the” Moro reflex”. early from a recurring nightmare. In the dream, This central insecurity, experienced on the a man had been shot in the head. His skull was slightest separation from total submission to the open and he was dying. The patient was holding narcissistic object, accounts for anxiety being him, waiting for the doctor to come. The man the most prominent of all symptoms of died just before the doctor came. depression, and why general psychiatrists often There were of course many striking aspects use the overall term “agitated depression”. to the presentation, including the inability for In her paper “On mourning and its reparation, as the patient could never forgive relationship to manic depressive states”, Klein himself for having committed his murderous also emphasised a central theme of insecurity attack. However the point that I wanted to 278 in depression, explaining it in terms of having highlight here was the patient’s waking early

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with the recurrent nightmare and then feeling his former ways. To speak to him one would worse in the morning, improving as the day have needed to know what part of his mind was went on i.e. his symptoms of early morning located in his big toe! This patient lacked any wakening and diurnal mood variation. insight and all treatment inevitably remained at We have an internal as well as an external a physical level. However, it does not stop ones world, and this helps to make sense of the analytic interest in the way his mind was patient’s experience at a psychological level. functioning. The patient wakes up early to get away from a One therefore has to accept that, for some terrifying and critical internal world. Patients with people, the severity of their psychopathology is depression feel worse on wakening as they find such that one is left only being able to treat themselves totally dominated by their them at a physical level. Others unforgiving internal world. As the day psychopathology might not be so severe and, progresses they start to feel better as the while taking medication, come for external world is a far more humanly responsive psychotherapy, while others may opt purely for one than their internal world. Consideration of a psychotherapeutic approach. this dynamic may also introduce a way of talking In some patients in psychotherapy, with the patient and his relatives about the medication can reduce the intensity of internal experience. symptoms when threatening to become incapacitating, for example when rendering the THE PLACE FOR MEDICATION patient unable to get up in the morning to make their analytic sessions or in lessening suicidal Since all feelings are to be repressed (the feelings when threatening to become calm sensible person with no feelings), they overwhelming. The doctor prescribing the may be projected into the body and felt only as medication, whether the general practitioner or physical sensations, referred to as ‘depressive specialist, could work in harmony with the equivalents’. While depression raises analytic psychotherapist, provided there was a fascinating questions of the relationship mutual understanding of how ill was the patient between the mind and bodily experiences, as and there was agreement on the purpose of transmitted through neuronal networks, at the each aspect of the treatment plan. end of the day, we may be left with a patient with Including the marital partner in no insight seeking relief from very distressing management is most important in all cases of physically experienced symptoms. This is where severe depression. The partner needs support antidepressant and anxiolytic medication enter and education in the dynamics of the disorder in the picture. order to endure extended periods where the A patient gave a history of being a corporal patient will not listen to their advice. in the army many years ago. When age 30, he In this context, an understanding of had an attack of pericarditis. This destroyed his transference and counter-transference issues delusion of immortality. He held onto this belief presenting in depression, may help the patients, by projecting his anger at such a loss into his their relatives and professionals in body. He became consumed with understanding and coping with the experience. hypochondriasis complaining of pain in every organ. If visitors came round to see his family, THE TRANSFERENCE AND COUNTER – he would dominate the conversation and talk of TRANSFERENCE IN DEPRESSION pain from his big toe to his testis, abdomen, chest and head. The Transference If it became too much for the family he would be admitted to give them respite and he If one considers a major depressive episode would receive medication or ECT. I inherited in terms of a psychotic episode, then one cannot him when he was in his sixties. On admission, rely on ones ordinary empathy, but has to tune he again talked incessantly about his symptoms. into a particular wavelength to make sense of However, I was struck by how he managed to the disorder and understanding the transference chase the female nurses round the ward with phenomenon. his walking stick, in a sexually provocative way. There is an expectation that things should Interestingly on the morning of his birthday, his never have gone wrong. The object relationship mind temporarily returned to his head. He is to a god-like figure. If anything goes wrong, behaved normally, in a patient’s group, inquiring someone is to blame because it could have as to other patients’ welfare. He then reverted to always been prevented from happening in the 279

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first place. There is no desire for understanding, (Lucas, 1998). only in returning to a previous trouble free state. I will conclude the paper with an elaboration An example would be the story of the man about the two superegos, a mature benign driving a car who knocks over another man reflective one, and the ego destructive superego riding a motorbike. The motorcyclist is lying on taking over in depression, as it provides an the floor unconscious. His motorbike is in overall framework to our approach to flames. The driver gets out of his car and beats depression. himself on his chest saying to himself, look what a terrible person you are for what you have THE SUPEREGO IN DEPRESSION done, but does not lift a finger to help the motorcyclist. Freud’s introduced the term ‘Superego’ in This leads onto the counter-transference “”11. He described how one experience for those trying to help the patient part of the Ego sets itself over against the other whether psychiatrists, analytical therapists or and judges it critically. The superego relatives. incorporated his previous concepts of the dream censor, special agency, ego ideal and 16 The Counter-transference unconscious sense of guilt . Klein described an early pre-oedipal stage The first issue to be appreciated is the clash to the formation of the superego, with a very of interest between the patient and the carers. harsh superego in evidence at the , Whilst the patient is not interested in gaining which becomes modified over time, with insight, just wanting to regain a previous illusion experiences, to becoming more benign, less of perfection, the therapist or relative is trying to demanding and more tolerant towards human persuade the patient not to be so demanding frailties5. and critical of themselves and take a more Freud commented on the particular nature reasoned, forgiving and understanding of the superego operating in relation to approach. Melancholia, noting an “extraordinary The counter-transference for the carer harshness and severity towards the ego” in both becomes one of frustration and irritation, as obsessional neurosis and melancholia (p.53)11. anything that is offered in terms of helpful advice However, it was more dangerous in Melancholia is rejected, while the patient persists in where it was “a pure culture of the death remaining in a troubled state. (which) often succeeds in driving the ego into While the process of self-berating goes on, death” .(p.53).11 it feels for the professionals and carers that Klein also referred to an early very harsh there is no sign of light at the end of the tunnel superego that stood apart and was unmodified and that the process will on forever. Often the by the normal processes of growth, leading to patient will ask also if their state of depression consideration of a different superego operating will ever end. The carers need help to appreciate in depression17, 3. that the self berating over the loss of the illusion Bion outlined the characteristics of this ego- of perfection, is an internal process that will go destructive superego in the following way, “It is on with a momentum of its own until it abates, a super-ego that has hardly any characteristics and the carer may need help not to take of the super-ego as understood in rejections of their offered help, by the patient, in psychoanalysis: it is ‘super’ ego. It is an envious a personal way. assertion of moral superiority without any Of course, the issue of support for the morals” (p.97)18. He further comments, “In so far relatives becomes much more pressing when as its resemblance to the super-ego…shows manic states arise, where there is a component itself as a superior object asserting its of triumphing over the object of dependency, superiority by finding fault with everything. The which is projected onto the nearest relative, most important characteristic is its hatred of any with acting out behaviour of verbal abuse and new development in the personality as if the sexual affairs. This has potentially a very new development were a rival to be destroyed” destructive on relationships and a later real risk (p 98)18. of suicidal behaviour, once the patient has come The following serves as a telling example of down from the manic state. In such the extraordinarily murderous quality to the ego- circumstances, it is even more important to help destructive superego. A patient with a long and support the relatives in understanding and history of depression had reached mid-life. 280 coping with their counter-transference feelings There was no previous history of self-harm. He

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had never worked and lived with his mother until movement. The active involvement of the she died two years previously, when he went to therapist on the side of a mature reflective live with his single brother, who went to work. superego, helped lessen the effects of the ego- He spent his days visiting different sisters who destructive superego and support the remained very loving and supportive. He had development of her own mind. recently become some-what more agitated, but persistently denied suicidal feelings, including CONCLUSION on the very day that he actually killed himself by multiple stabbing with a kitchen knife, with his In this paper, I have endeavoured to draw brother returning from work to find him dead. attention, with clinical illustrations, to certain His family needed help to make sense of it key issues when thinking about the all, and how their loving feelings had been management of depression and why in some appropriately directed in supporting a cases patients may receive analytic dependent part that had never been allowed to psychotherapy, in others antidepressant develop by the ego-destructive superego. When medication, and in some a mixture of both. reaching mid-life and faced with having to It is important to distinguish major account for its destructiveness in never having depressive episodes from other ways that we allowed the patient to develop a life, the think of low moods. If we regard major murderous part turns on the ego and kills it. It depressive episodes as manifestations of an was interesting that in the discussion afterwards underlying psychotic disorder, then it means with the relatives, a sister recalled how months that we need to make a special effort to tune previously, the patient had said that his body into the wavelength of the psychopathology in was tired of living, suggesting that the ego was order to understand it and become empathic to located in the body awaiting to be attacked by the ongoing process. the superego. Psychoanalysis as well as biological Bion’s hypothesis19 was that the psychiatry has much to contribute in the pathological superego arose out of early failures understanding and management of depression, in communication between the infant and and it is suggested that a biological and a mother. In depression, the ego-destructive psychoanalytic approach are not necessarily superego will occupy the driving seat and attack mutually incompatible. the self. In such a situation, O’Shaughnessy Analytic theory in describing the presence summarises, “No working through can take of an abnormal ego-destructive superego, place, only an impoverishment and deterioration operating in depression, suggests an overall of relations, with an escalation of hatred and framework of approach to treatment. The priority anxiety that results in psychotic panic or in treatment, whether through medication or despair. In this dangerous situation, the analytic psychotherapy, would be to unseat the significant event for the patient is to be enabled primitive ego-destructive superego, which has to move away from his abnormal superego, usurped the driving seat that otherwise would return to his object, and so experience the have been occupied by a more mature and analyst as an object with a normal superego” reflective superego. Only when the reflective (p.861).3 superego is back in place can any meaningful To end on a more positive note, in contrast analytic work go on towards strengthening the to the previous example, there are also cases ego or individuality of the person. where patients may actively seek help through analytic psychotherapy. A young woman came to therapy with a REFERENCES five-year history of disabling depression. She 1. Freud S. (1917). Mourning and Melancholia. S.E.v14. had been hospitalised early in the illness and 2. Abraham K. (1924). A short study of the development of had been on antidepressant medication for a the libido, viewed in the light of developmental disorders. number of years. She came from a strict In Selected Papers of . London: Hogarth, religious background. Her wish was to develop p93-109. 3. O’Shaughnessy E. Relating to the Superego. Int. J. her own mind, while facing up to the guilt of Psychoanal,1999; 80, p861-870. developing a different attitude to her parents. 4. Jacobson E. Depression: Comparative Studies of Nor- She was determined to come off medication. mal, Neurotic & Psychotic Conditions. New York: Interna- She described the feelings in therapy as going tional Universities Press, 1971. round and round over painful events; however it 5. Segal, H. Introduction to the work of Melanie klein. Lon- don: Hogarth Press, 1973. was like a spiral coil, so that there was a forward 281

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6. Stengel E (1969). Suicide and Attempted Suicide. with a more mature superego providing an overall Harmondsworth:Pelican Books. framework of approach to treatment. 7. Lucas R. (1994). Puerperal psychosis: vulnerability and aftermath. Psychoanal Psychother. 8; p257-272. Keywords: Depression, medication, psychoanalytic 8. ICD-10. Classification of Mental and Behavioural Disor- framework, ego-destructive superego. ders: Clinicla Descriptions and Diagnostic Guidelines: World Health Organization, 1992. RESUMO 9. Gelder M, Mayou R and Cowen P (2001). Shorter Oxford Textbook of Psychiatry. 4th Edition. Oxford University Press.. Pacientes com depressão abrange um espectro, 10. Klein M. (1935). A contribution to the psychogenesis of em termos da severidade da psicopatologia, entre os manic-depressive states. In Writings of Melanie Klein. que se tratam com psicoterapia psicanalítica e os que London:Hogarth. Vol.1.p262-289. recebem tratamento medicamentoso. Neste artigo o 11. Freud S. (1923). The Ego and the Id. S.E. v19. autor demonstra como o referencial psicanalítico tem 12. Freud S. (1914). On Narcisism. S.E. lugar no segundo grupo e pode ajudar o psiquiatra 13. Klein M. (1940). Mourning and its relation to manic-de- clínico a tratar seus pacientes deprimidos. A noção pressive states. In Writings of Melanie Klein. da patologia autodetrutiva do superego é explorada London:Hogarth.Vol.1. p344-369. no controle da depressão com a necessidade de 14. Bion W.R.(1957) Differentiation of the psychotic from the atingir a um superego mais maduro promovendo uma non-psychotic personalities. In Second Thoughts. New York: Aronson. 43-64. estrutura à abordagem do tratamento. 15. Lucas R. (1998). Why the cycle in a cyclical psychosis? An analytic contribution to the understanding of recurrent Descritores: Depressão, medicação, referencial manic-depressive psychosis. Psychoanal Psychother. 12. psicanalítico, superego autodestrutivo. p193-212. 16. Laplanche J., and Pontalis, J-B (1973). The Language of Título: O manejo da depressão – análise, antidepres- Psycho-analysis. London:Hogarth Press. sivos, ou ambos? 17. Klein M. (1958). On the development of mental functio- ning. In Writings of Melanie Klein. London:Hogarth. Vol.3. RESUMEN p236-246. 18. Bion WR. (1962). Learning from Experience. London: Karnac.97. Pacientes con depresión abarca un espectro, en 19. Bion WR. (1959). Attacks on Linking. In Second Thou- términos de la severidad de la sicopatología, entre ghts. New York: Aronson, p93-109. los que se tratan con psicoterapia psicoanalítica y los que reciben tratamiento medicamentoso. En este artículo el autor demuestra como el referencial COMPLEMENTARY REFERENCE psicoanalítico tiene lugar en el segundo grupo y puede ayudar el psiquiatra clínico a tratar sus Freud S. (1933). New Introductory Lectures on Psycho-analy- sis. S.E. 1933. pacientes deprimidos. La noción de la patología auto- destructiva del superego es explorada en el control de la depresión con la necesidad de alcanzar un ABSTRACT superego mas maduro promoviendo una estructura al abordaje del tratamiento. Patients with depression cover the spectrum, in terms of severity of psychopathology, between those Palabras-clave: Depresión, medicación, referencial receptive to analytic psychotherapy and those that psicoanalítico, superego autodestructivo. require treatment with medication. In this paper, the author demonstrates how a psychoanalytic framework Título: Gerenciando la depresión – analítica, antide- of understanding has a place in the latter group, and presivos o ambos? can aid general psychiatrists in relating to their depressed patients. The notion of a pathological ego- Dr. Richard Lucas destructive superego taking over control in depression St Ann’s Hospital, London. is explored, with the need to unseat it and replace it [email protected]

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